Night to Shine is an unforgettable prom night experience, centered on God’s love, for people with special needs 14 years and older. We will serve as one of the more than 500 churches around the world hosting a Night to Shine simultaneously on Friday, February 8, 2019.

If you need help with this form or have questions, please email fchfa.nts@gmail.com.

Guest First Name*

Guest Last Name*

Date of Birth (mm/dd/yy)*

Gender*

MaleFemale

Address*

City*

State*

Zip Code*

Emergency Contact Name*

Emergency Phone #*

Let's make this night amazing!Tell us more about the guest:

Health Concerns*

Will Guest Attend in Wheelchair?

NoYes

Special Communication Needs*

Sensory Issues/Concerns*

Is guest providing a personal buddy?All guest provided buddies MUST sign-up separately as an event volunteer and follow volunteer guidelines. Night to shine is prepared to provide a buddy for each guest, however, we recognize that some guests prefer to provide their own escort buddy.

YesNo

Allergies*

Special Food Needs*

Prom Attire Needs*

Hair styling the day of the event?(Male or Female)*

YesNo

Makeup the day of the event?*

YesNo

Parent/Caretaker Information

Parent/Caretaker Name(s)*

Parent/Caretaker Phone #*

Parent/Caretaker e-mail*

Care for the CaretakersWe want to make the night fabulous for everyone. We have a special area reserved for up to two of the participant's caretakers to enjoy the night. Space is limited. So, please let us know how many we can expect.

Number of Parents / Caretakers staying for event?*

012

Legal Stuff: Can we use guests photo and video?For the good and valuable consideration of participating in an event hosted by Fellowship Church, and sponsored in part by or associated with the Tim Tebow Foundation, I hereby give my full consent to Tim Tebow Foundation, Inc., (“TTF”) a Georgia nonprofit corporation headquartered in Florida and Fellowship Church, a Louisiana nonprofit corporation, to record, by writing, by video, photographic, or audio recording device, or by any other analog or digital means, my actions, physical likeness, biographical information, and/or voice. Additionally, I hereby grant to TTF and Fellowship Church, without royalty or other compensation now or in the future, all rights of every kind and character whatsoever, in perpetuity, in and to any and all such recordings, along with any additional recordings I might provide to TTF and Fellowship Church, and to any benefits inuring to TTF and Fellowship Church as a result of its use of any of the foregoing recordings. Among other things, TTF and Fellowship Church may, but are not required to, copy or reproduce the recording, edit or modify it, incorporate it into another work, display or broadcast it or any of the foregoing privately or publicly, and use or license it or any of the foregoing for use by others, all for the sole benefit and at the sole discretion of TTF and Fellowship Church, for the advancement of TTF and Fellowship Church’s exempt charitable purposes. All permissions granted herein extend to any successor or assign of TTF and Fellowship Church and bind me and my heirs, successors, and assigns. I, hereby release and discharge and agree to hold harmless TTF and Fellowship Church, its directors, officers, employees, volunteers, and independent contractors, from any and all claims or damages, including but not limited to defamation or violation of rights of privacy or publicity, arising from or associated with the recording or use of the recordings. This release shall be construed, interpreted and governed in accordance with the laws of the State of Louisiana, and should any provision of this release be determined invalid, such invalidity does not affect any of the remaining provisions. I am of full age and have the right to contract in my own name.

I read and accept Night to Shine's Media release?*

YesNo

Final Notes:If you need help with this form or have questions, please email fchfa.nts@gmail.com.